In most cases, GPs find themselves with a problem despite their best intentions.
Tapering patients is easier said than done.
The consequences of inappropriate prescribing, especially when dealing with vulnerable patients and addictive medications can be serious and is an issue that makes up a high number of calls for help to medical indemnity insurer Miga.
While systemic issues like overwork and time pressure can contribute to lapses in medical care, there can be other factors that complicate a doctor-patient relationship and exacerbate the risk of inappropriate prescribing.
In most cases, GPs find themselves with a problem despite their best intentions, says Anthony Mennillo, head of Miga’s Claims and Legal Services.
“General practice is where the issue seems to arise more frequently, for example where there are patients who have chronic pain or mental health issues and require opioids and/or benzodiazepines,” he explains.
“These can often be very difficult patients with very genuine but complex long-term issues, and there is a significant risk that the doctor can lose control of the prescribing.
“The doctor wants to do the right thing by the patient, but then the patient starts coming back earlier for more medication, particularly opioid medication.
“It can be easy for the doctors to lose track of how much is being prescribed until something happens.”
And that something can often be very serious, resulting in an official complaint, and in the following situation, the death of a patient.
In 2024 a regional Queensland general practitioner was suspended after a tribunal found he inappropriately prescribed addictive medications to a patient who later died.
The GP, who practiced at a high-volume bulk-billing clinic, treated a patient known as MD over a five-year period. MD, who had a complex history of physical and mental illness, had been flagged by a psychiatrist as being at ongoing risk of self-harm and suicide, and had previously shown violent behaviour towards clinicians.
Despite these risks, the GP prescribed MD multiple medications – including anti-anxiety drugs, antidepressants, antipsychotics, weight-loss drugs, and the opioid oxycodone – without obtaining the legally required authorities. The coroner found that oxycodone contributed to MD’s death in February 2021.
This led to a complaint and a Medical Board of Australia investigation that saw the GP referred to the Queensland Civil and Administrative Tribunal.
The tribunal heard that the GP was seeing approximately 40 patients per day, many of whom had complex health needs often complicated by exacerbating non-medical factors – many of the patients were indigenous or migrants, and many were elderly and reliant on government benefits.
According to the tribunal transcript, the GP conceded this particular case had been a difficult one to manage.
“[MD] was far and away the most complex and difficult patient of my career,” the GP deposed.
“When I look back at my treatment of him, I can now clearly see that I was out of my depth and should have, at many points, recognised this and either sought specialist assistance, or referred him on to another general practitioner specialising in patients with extremely complex care needs.
“My failure to do this may become a little more explicable with further information I provide, but I accept that this information will not take away from the gravity of my errors, nor does any of the information change the fact that [MD] did not receive the standard of care which he was entitled. It was my responsibility.”
The tribunal found the GP had engaged in professional misconduct by failing to meet regulatory requirements for prescribing Schedule 4 and Schedule 8 drugs and by not maintaining adequate records or a treatment plan.
It reprimanded the GP, suspended his registration for three months, and imposed a 12-month period of supervised practice.
Since the investigation the GP has reduced his patient load from 40 to fewer than 30 per day, allowing him more time to complete clinical notes and improve the quality of care.
Mr Mennillo says this is a good example of how time pressures, the impact of a potentially volatile patient and a doctor’s desire to help can go wrong.
Adhering to legal requirements to obtain an authority to prescribe where required, using the safe script or script check service available in each state, keeping clear and detailed records around consultations and prescribing, including the reasons for prescribing, were vital in the event that a doctor is called on to explain their prescribing.
“What tends to happen when it comes to continued prescribing is that the expected standard of record keeping slips heavily and quite often,” Mr Mennillo says.
“There might be only one or two words in the notes, such as repeat prescription for something like oxycodone or diazepam and the notes are otherwise non-existent.
“It’s a real red flag. We’ve often helped doctors that have a complaint to AHPRA, for example, and when we review the notes, it’s hard to justify and defend the management. It is even worse if the patient has died – for example, of mixed drug toxicity.
“There’s no overall documented management plan for the patient, which the Medical Board expects to see for complex patients. There should be a multidisciplinary approach with difficult patients. It can’t be just the GP prescribing.
“There needs to be pain clinic involvement, if that’s available, there need to be psychologists or psychiatrists or some other physician – someone reviewing the patient and giving a second opinion on the patient’s management.”
Mr Mennillo says it is often the kind and sympathetic doctors who end up getting into difficulties.
“They want to keep their patients happy, find it hard to say ‘No’ and they keep prescribing and it gets out of control,” he says.
Doctors can say no to requests for prescriptions, particularly Schedule 8 medications and those subject to abuse/misuse, and should feel empowered to do so, even with difficult patients.
“They need to be in control of the doctor-patient relationship, and if they think that medication is no longer clinically indicated or not indicated at the dose the patient is at, they should be weaning the patient off it,” Mr Mennillo says.
“Then they can say, I will not be prescribing that anymore, and if you want me to continue to be involved in your care, we need to slowly reduce your medication. Of course, that is often easier said than done.”
Mr Mennillo says complaints from patients about doctors refusing to prescribe opioid medications do occur but are less common and the Board consider these types of complaints differently.
“That’s what the Board wants to see – a doctor who is willing to stand up and say there is a good reason for not prescribing it or trying to reduce the dosage,” he says.
“If it was clinically indicated and it wasn’t prescribed that’s a different issue, but most often those type of complaints come from drug dependent individuals who will sometimes use the complaint as a threat to get the doctor to continue prescribing.
“It does put the doctor in a tricky situation, but that’s where I think the doctors have got to be brave enough to stand up to the patient (sometimes peer support or a second opinion will assist) and to accept there might be a risk that there will be a complaint and their prescribing will be investigated. It’s far better to put a stake in the ground if they feel that is the right thing to do and say, ‘that’s enough’. And of course, once the patient has made a complaint the doctor can legitimately decline to ever see that patient again.”
